Residential Services Practice Manual 3Rd Edition Part 1

Residential Services Practice Manual 3rd Edition – Part 6

In this section

6 Records and procedures 6.1 Introduction to public records 6.1.1 Records kept by residential services 6.1.2 Client Relationship Information System (CRIS) 6.1.3 Personal information privacy and access 6.1.4 Freedom of information 6.1.5 Storing, maintaining, moving and archiving files 6.2 Accountability of money 6.3 Handling funds in respite services 6.4 Critical client incidents and non-critical client events re-issued October 2015 6.5 Damage caused by people living in residential services 6.6 Missing people 6.7 Responding to physical and sexual assault 6.8 When a person dies re-issued July 2013 6.9 Wills and deceased estates

RSPM application to service type Each instruction has service type and instruction application codes to assist to identify how the specific instruction applies to supported accommodation by service type. Service type:

FBR facility based respite GH group homes

STJ short term justice LTR long term rehabilitation program

I Sandhurst and Colanda RTF residential treatment facility (DFATS)

Instruction application:

Y instruction applies in full

N instruction does not apply to service type

Partial application. Service required to implement principle of instruction but service not generally P directly responsible for planning, monitoring and reviewing components of instruction

Locally determined based on client plans, service model and protocols. Applicable to STJ, LTR and RTF LD only

If this document has been printed or saved, ensure it is current before using it by checking the issue date matches the online version. Residential Services Practice Manual 3rd Edition – Part 6

If this document has been printed or saved, ensure it is current before using it by checking the issue date matches the online version. Residential Services Practice Manual 3rd Edition – 6.1-1

6.1 Introduction to public records

Issued: August 2012 Applies to all Contents What are public records? Why are public records important? Public records in residential services Legislation and policy directs records management Standards for written records Resources

What are A public record is any record made or received by a public officer in the course of public records? their duties. Records come in a variety of formats and media including:  hardcopy documents  emails  computer files  letters  scanned documents  web pages  maps  plans  photographs. Disability Accommodation Services staff are public officers. A public officer includes anyone employed by any department, branch or office of the Government of Victoria including permanent, part-time and contracted staff.

Why are public Records demonstrate how the Department of Human Services is accountable for records decisions and actions and how it complies with legal, financial and business important? requirements. Records provide proof of services provided to clients, business practices, communications, decisions and actions. Records generated in residential services are the collection of information necessary for Disability Services to provide evidence of the support which has been provided to residents.

Public records In the course of a working day, all information which provides evidence of the in residential work undertaken must be retained as a record. Records must be created whenever services there is a requirement for accountability and evidence of decisions made and actions taken. The Accommodation Services File (ASF) is the public record of the support provided to a resident in a residential service.

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Legislation and There are legal and policy requirements for government departments which places policy directs significant responsibility on all public officers. Based on these requirements, all records records collected or received must be treated in accordance with the provisions of management the legislation which governs practice and the department’s policy on records management. For disability services the following law and policy applies:  Victorian Public Records Act 1973  Information Privacy Act 2000  Health Records Act 2001  Disability Act 2006.  Evidence Act 2008  Freedom of Information Act 1982  Residential Services Practice Manual 2011  Department of Human Services Records Management Policy (10/001)

Standards for The majority of records created are subject to the Freedom Of Information Act written records 1982, so all records must be:  factual and non-judgmental  legible  logical and sequential  signed and dated  appropriately cross-referenced, for example, if a letter from an administrator is filed in the finance section of a person’s file, this should be noted in the daily communication record. Staff must not:  use white-out to correct mistakes; mistakes must be crossed out with a line through the text and initialled  archive or store documents in plastic sleeves which can cause printed information to deteriorate  file faxes or documents on thermal paper as these deteriorate over time; these documents must be copied onto standard paper before filing  use jargon. Avoid acronyms or abbreviations to ensure information is clear to any reader  use abbreviations or nick-names of staff or residents. In addition:  the use of red pen should be avoided as it may become illegible if it needs to be photocopied for a formal process, such as an investigation by police or the coroner.

Resources  DHS Business Support Records Management – policy, fact sheets and resources that describe requirements for records management. Available on the DHS Hub.

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6.1.1 Records kept by residential services

Issued: August 2012 Applies to all Contents Overview Security of records within residential services Security of records taken to external appointments Portable data storage devices What are resident records? Electronic documents How are residents identified in the system? How do group homes get ASF’s How is the ASF used? What are operational records? How are operational records managed? Role of staff Role of supervisor and manager Resources

Overview All documents and files created and used within residential services are known as records. The records kept in residential services relate to both residents and the general operation of the service site. The records required to be completed are specified in each part of this manual.

Security of Records must be securely kept in locked storage when not in use to ensure records within protection from: residential  unauthorised access, see RSPM 6.1.3, 6.1.4 services  tampering  damage or destruction

Security of When information held on a resident’s file is required for an appointment outside of records taken the residential service, for example, a specialist medical appointment, staff must to external ensure that the record is: appointments  in a secure non-transparent document envelope  limited to only the specific information required for the appointment  never saved to an unsecured portable data storage device.  never transported loose or with information visible  not left unattended in any place at any time  kept with the staff member at all times. A note should be included in the diary or shift report, to identify what records have been removed from the residential services, and when they were returned. This should include the date and time the information was taken and returned.

Portable data Portable data storage devices must only be used for resident records if they storage devices approved and provided by the Information management and technology units. These devices include:  USB memory sticks  personal digital assistants (PDA’s) such as palm pilot and Blackberry  digital audio players such as iPods and MP3’s  mobile phones and smart phones  lap top computers  removable storage media such as CDs and memory cards. Resident information must never be saved to staff members’ personal device under any circumstance. Where portable electronic storage devices such as a USB, may be required they must be requested via the manager to the division Information Technology services. The devices supplied will be encrypted to ensure that any information is secure and only able to be accessed with passwords or codes. Residents may use personal devices to store personal photo’s or other information and these are not subject to records management requirements.

What are The official corporate file for resident records is the Accommodation Services File resident records? (ASF). Resident records include, based on resident support needs, but are not limited to:  personal profile  health support  personal care  person centred active support and daily routines  support assessments and plans  Critical Client Incident reports  financial plans These records are documents that:  describe support needs and services used by department clients  keep a history of how support is provided to each person.

Electronic Electronic documents include resident plans written on the computer, emails, documents scanned documents and photo’s. Saving documents to the residential service computer, is not part of the official client information management system like CRIS. Documents required to guide support, or that contain information about a resident (including emails), must be printed and placed in the relevant section of the ASF in accordance with the department’s records management policy.

How are There are two official sources which keep client information. One is the Client residents Relationship Information System (CRIS), which allocates a number to every person identified in who is registered for services with the department. This number forms the basis for the system? all reference numbers relating to the client records and the services which they receive from the department. Residential services may not currently use or access CRIS however a resident’s CRIS number must be on all files to ensure records can be registered to the right person in the Total Records Information Management (TRIM) system. When a new ASF is requested, the file folder will have a bar coded label attached to ensure the system knows the location of a resident’s records. The two systems, CRIS and TRIM combine records to give the complete resident history.

How do group The ASF is the corporate file which is used to record client information in homes get ASF’s residential services. All ASF files must have a TRIM label attached to the cover before information is placed in the file. To obtain a new ASF for a resident contact either the DAS administration or the division records management unit, as required by the divisions process. Records staff will register the ASF to the resident by the CRIS number, on the TRIM system. The file will be sent to the residential service via the local process.

How is the Each resident has an ASF where all records must be kept in the relevant section. ASF used? The ASF is the registered corporate file and is to contain one year of records. Each ASF should not be more than 5cm in thickness. Where a resident requires a large amount of records to be kept that causes the ASF to exceed the 5cm thickness, then a new ASF part should be requested. Parts will be used to form a series of information relating to the resident during the year which should be maintained in sequential date order. To manage retrospective organisation of ASF’s, the date range of the contents may be included as a reference as some of these files may not be sequential. When information contained in the file is more than one year old but remains current and required, it is to be transferred to the new ASF. A note that the document remains current and the date of transfer to the new file, is to be noted on the top of the document. For example a letter from the neurologist with safety instructions for a person with epilepsy. This document should be verified as still being current by notation of date and who verified the information, see RSPM 6.1.5. Records are to be placed into the relevant corresponding ASF section.

What are Operational records capture the day to day operation of the residential service that operational are not specific to an individual resident. These include: records?  diaries  general shift reports  staff roster and shift replacement  household and staff routines  shopping and menu planning  household budget and finance information  minutes of both staff and resident meetings.

How are An Administration file (ADF) is the official corporate file that is to be used to operational manage operational records. An ADF is requested from division records records management. Each year, corporate files should be created for each specific type of managed? information, for example there will need to be a file for house meeting minutes and a separate file for household budget and finance documents. These files are registered in the TRIM system. At the end of each calendar year the documents are to be moved to the archive, see RSPM 6.1.5.

Role of staff All staff are responsible to complete and store required documentation on every shift. This will include but is not limited to:  shift reports  diary entries  resident support including health, medication, Person Centred Active Support (PCAS)  shift handover tasks such as cash counts In addition, staff are required to ensure:  they adhere to the standards for written documents, see RSPM 6.1  all records clearly show the date of creation and, where required, a review or end date  the name of the staff member who wrote the record is recorded  document copies or those in draft are marked accordingly as only the most current and correct information is to be used.

Role of The records management responsibilities of individual staff and managers are supervisor defined in the Department of Human Services Records Management Policy and and manager Department of Health Records Management Policy. The supervisor and manager are required to ensure:  staff complete all records as required  information is kept secure and only available to people who have a legal right to access the information  ASF’s and ADF’s are updated each year  the previous years records are managed as required, see RSPM 6.1.5  staff are trained in records procedures which relate to their work

Resources File/health note template – a template to use for recording file notes or health notes for the resident file. It is available on the DAS Hub. Resident profile template – a template to record a brief resident profile. It is available on the DAS Hub.

6.1.2 Client Relationship Information System (CRIS)

Issued: August 2012 Applies to all Contents What is the Client Relationship Information System (CRIS)? What information is held in CRIS? What is information in CRIS used for? Who enters information in CRIS? Resources

What is the Client The Client Relationship Information System (CRIS) is the primary electronic file Relationship system used to document client support information required by Disability Services. Information All people who are eligible for services and request support must have a CRIS file System (CRIS)? created. CRIS is not always used by residential services and the Accommodation Services File (ASF) remains the formal corporate record for residential services.

What information CRIS stores information about: is held in CRIS?  Critical Client Incidents or significant events  contact with family or others which may impact on support needs  changes in resident behaviour or health issues  support plans  information which may result in health or welfare risks  issues which require specific action  information and copies of legal or formal orders, such as guardianship or supervised treatment orders.

What is CRIS information is used to provide: information in  individualised support CRIS used for?  a summary of data service use, for example, the Federal Government often requires statistical information to determine on-going funding requirements.

Who enters Staff with CRIS access may enter their case notes, health information, individual information health plans, Critical Client Incident reports and alerts onto the system based on in CRIS? division direction.

Resources  CRIS, CRISSP, FERIS – client electronic records system. Resources tolls and information http://intranet.dhs.vic.gov.au/corporate-service-hubs/technology/cris-crissp- feris

6.1.3 Personal information privacy and access

Issued: August 2012 Applies to all Contents What is personal information? Privacy of personal information Who can access personal information? Who has legal authority to access personal information? Resources

What is personal Personal information is any information, or opinion, which directly or indirectly information? identifies a resident. This includes:  personal profiles  plans  case notes  file notes  health information. This information is held in a resident’s file. This includes the Client Relationship Information System (CRIS) file and the Accommodation Services File (ASF).

Privacy of Residents have a right to have their personal information remain private unless personal disclosure is required, or authorised by law, see RSPM 6.1. Residents can expect information to:  have personal information provided to others on a ‘need to know’ basis only  have personal information stored securely  be informed before any personal information is disclosed in situations where it is practical and desirable, to do so.

Who can access Access to personal information held in resident files is restricted to: personal  the resident, or their guardian or administrator with authority in the relevant information? area, for example, an administrator can only access financial records  staff working in the residential service (including casual staff) who require the information to provide support  other departmental staff with a legitimate business need  professionals employed to provide services such as health professionals who need to access or record information to ensure the wellbeing of the resident  those with legal authority

Who has legal Under the Disability Act 2006, the following people can access a resident’s authority to personal information without their consent. access personal Community Visitors, who can: information?  inspect any part of a residential service and see any resident, at any time, with or without previous notice  make enquiries about service provision  inspect any document relating to a resident which is not a medical record, this includes: – financial records – health files  inspect any resident medical records, with the consent of the resident or their guardian, as defined in section 37 of the Guardianship and Administration Act 1986. A medical record is a record created by a treating medical practitioner for a medical purpose, that is, for medical assessment, diagnosis and treatment. The Disability Services Commissioner, who can:  seek information from any service provider about the workings of their complaints system  ask questions about the resident, or their support needs. The Senior Practitioner, who can:  inspect and copy any document related to any resident they believe may be subject to a restrictive intervention or Compulsory Treatment Order  ask questions about the resident or their support needs. Victorian WorkCover Authority inspectors who can:  request any information they require to perform their role, which may include components of a resident’s file or health records. These requests must be referred to the Disability Accommodation Services manager.

Resources Corporate Integrity, Information and Resolutions Unit – provides information, advice, training and tools to support compliance with privacy legislation. Available on the DHS Hub.

Disability Act 2006 – provides a legislative framework to strengthen the rights and responsibilities of people with a disability, see: the Victorian Legislation and Parliamentary Documents website at: http://www.legislation.vic.gov.au

Office of the Public Advocate (OPA) – protects and promotes the rights of people with a disability, see: the OPA website at: http://www.publicadvocate.vic.gov.au

6.1.4 Freedom of information

Issued: August 2012 Applies to all Contents What is freedom of information? Freedom of information and disability client records Records exempt from freedom of information Resources

What is freedom The Victorian Freedom of Information Act 1982 gives people the right to: of information?  access documents about their personal affairs and the activities of government agencies  request incorrect or misleading information about them be amended or removed. The Act gives people the right to request information from:  state government departments  Ministers  local councils  most government agencies and statutory authorities  public hospitals and community health centres  universities, TAFE colleges and schools.

Freedom of Disability client records are subject to the Freedom of Information Act 1982. It is information and important staff are aware of this whenever they create a record. disability client records

Records exempt Some records are exempt from the Freedom of Information Act 1982 . For from freedom of example: information  documents which would involve unreasonable disclosure of information relating to the personal affairs of a person, including one who is deceased  health information about a person which would pose a serious threat to the applicant’s health or safety.

Resources Freedom of Information Act 1982 – provides a legal framework which enables people to access personal information about them held by the government. Available on the Victorian Legislation and Parliamentary Documents website at: http://www.legislation.vic.gov.au Freedom of information Unit – comprehensive information about freedom of information for department staff. Available on the DHS Hub. Privacy policy – provides the policy and guidelines to meet privacy requirements in the Department of Human Services. Available on the Department of Human Services website at: http://www.dhs.vic.gov.au/disability

6.1.5 Storing, maintaining, moving and archiving files

Issued: August 2012 Applies to all Contents Overview Why are records retained? How long are records retained? ASF in current use ASF from previous year ASF is archived after 3 years Transferring files when a resident moves location Role of the supervisor and manager Resources

Overview Residential services create and keep large amounts of records. Some records such as a personal profile are actively used over a long period of time, others are used short term, for example, continence charts. All information forms part of the department’s records about services provided and business decisions. When this information is no longer required for regular use or reference it is then managed in accordance with policy and legislative requirements known as archiving. Archiving is the process of managing records which are no longer considered to be active but may need to be referred to in the future. The Accommodation Services File (ASF) is the official department file for resident information. A new ASF should be created for each resident each year, and the previous year’s file can be archived. Staff and general household records must not be placed in an ASF. This information is managed in a separate house files and should also be archived on an annual basis.

Why are records Records are created and retained to: retained?  describe resident support needs  keep a history of how support is provided to each resident  provide evidence of actions and decisions in relation to resident support and the general management of the group home. Not all information is kept for the same length of time. A statutory document known as a Retention and Disposal Authority (RDA) specifies how long information relating to Disability Services needs to be kept.

How long are All information gathered and used in the provision of disability services funded and records retained? or managed by the department, are managed according to the RDA. The life span of documents reflects its importance and relevance to both the care of the resident and its legal or legislative requirement. For example, life spans of records range from:  Permanent, known as a state archive  temporary, only a specified time after the record ceases to be required. For example, this may range from 1 year after information is no longer referred to or up to 75 years after death.

ASF in Each ASF should contain one year of records relating to a client. At the end of each current use year a new ASF should be requested from the divisions records management unit and the previous ASF archived on site for 3 years. The archived ASF’s must be archived by DAS offsite after 3 years. All resident information is kept in their allocated ASF – do not place another resident’s information into some one else’s ASF. Check that documents are securely attached and the file does not contain items that should not be in the file, see RSPM 6.1, 6.1.1. ASF files must be kept in a locked and secured area, preventing unauthorised access.

Keep Do not keep Original information  multiple copies of the same document Notes (including sticky notes) related to a  draft information. record securely attached to relevant  old identification cards such as record. pension and health care, library or other membership cards Photos taken for support purposes– place  other information not relevant to into an a paper envelope and secured in the resident. the ASF.  items that are not documents, Note: resident’s personal photo’s are their see RSPM 6.1 personal property.

Resident information must never be placed into general waste or household recycle bins. Draft, copies and any other item that has resident, staff or address details must be placed in secure bins for destruction. These are available at local offices.

ASF from previous The ASF is placed into an archive box. The box must not be directly written on. year The archive box may contain more than one resident’s ASF’s for that year however it is advisable that residents with a large volume of documentation and multiple ASF parts use a dedicated archive box containing only that residents’ records. The archived records must remain on site at the residential service for three years. During this time, the archive box must be stored in a locked area. After three years the archive is sent to the records unit for processing. All staff must ensure that boxes are managed in accordance with safe manual handling practices. Note: Client finance ledgers will not fit into the archive boxes. The hard covers should be removed and the ledgers folded over to place into the box. Ledgers and ASF’s should be kept in a separate archive boxes.

ASF is archived At the end of three years the records stored in the archive boxes are transferred to after 3 years the division office. ASFs are stored according to division arrangements. This may be in the division office or on an offsite secure storage facility. The TRIM system allows history, content, location and retention status of records to be easily identified if required. The archive boxes should have a completed box contents form placed in the front of the box which clearly states:  what is contained in the box  residential service address  contact details date range of information Note: the boxes must not be directly written on. Resident information must never be placed into general waste or household recycle bins. Draft and copies must be placed in secure bins for destruction. These are available at local offices.

Operational Records related to the general operation of the residential service are kept in the records Administration file (ADF) and a new ADF should be commenced each year, see RSPM 6.1.1. The requirements for the management of the ADF content is the same as the ASF. The ADFs can be placed in the archive box with other operational records such as communication books and diaries. It is kept on site for 3 years and then transferred to division records management.

Transferring files File transfer occurs when a resident moves from one site to another within the when a resident service. Files are not transferred to external agencies. moves location The supervisor or manager responsible where the file is located must:  check prior to transfer to make sure that all information has been filed appropriately  make arrangements for the file to be transported securely  attach the file transfer form to the front of the file ensure that details are filled in correctly, including details of the person who will receive the file. The supervisor or manager responsible at the file’s destination must:  ensure that file is received intact  complete details on the File Transfer form  copy the completed File Transfer form and return a copy to previous location  attach the File Transfer form to the ASF to ensure that when it is sent in for archiving that the information can be updated in the TRIM system.

Role of the The supervisor and manager are required to have a system in place to ensure supervisor records are: and manager  managed in accordance with Department of Human Services Record Management Policy and Disability Services statutory obligations  stored in a secure location within the residential service  transferred securely to division offices: – at the end of the three year on site storage requirement – when a resident is deceased or leaves the service.

Resources  File Transfer form – a form that must be completed when files are transferred. Available on the DAS Hub.  Information management – records storage and management information, policies, procedures and contacts on the DHS Hub.  Information management – security policies, procedures and contacts on the DHS Hub.  Records education unit resources and guides. Available on the DHS Hub.  Archiving records in Disability Accommodation Services – a visual guide to managing the packing and management of archive box contents. Available on the DAS Hub.  Public Records Office Victoria – PROS 08-13 Authority – Retention and Disposal Authority for Records of the Disability Services Function. Describes the retention period required for documents and who is authorised to dispose of documents that are not kept as a permanent public record. Available at: http://prov.vic.gov.au

If this document has been printed or saved, ensure it is current before using it by checking the issue date matches the online version. Residential Services Practice Manual 3rd Edition – 6.2 – 1

6.2 Accountability of money

Issued: August 2012 FBR – N GH/I – Y STJ/LTR/RTF – LD Contents Accounting for money Resident’s who don’t require assistance with money Staff accountability for funds Monthly statements of client funds The financial plan Unplanned expenses Resident inclusion Resources

Accounting for Staff are required to account for all resident and department money expended. The money systems designed to manage and account for money used at the group home are there to:  protect the funds of residents who cannot manage their own money  ensure compliance with departmental financial management and accountability requirements, see RSPM 6.1 provide reports to financial administrators. The system is designed to keep a record of:  all money held on behalf of residents in the Resident Trust Fund  bank account transactions by staff who hold cards to access accounts on behalf of clients and the house  how residents’ money has been spent

Resident’s who Residents who do not require any staff assistance and independently manage their don’t require own money are not required to participate in the Resident Trust fund processes. assistance with If staff are required to handle any client funds for any purpose they must be money accounted for via the Resident Trust Fund process. The funds of respite and emergency accommodation service users are managed by a separate process.

Staff Staff are accountable for all funds they handle so must document all expenditure as accountability required in the relevant ledger and ensure receipts are provided. Staff must not use for funds funds or resources intended for use by residents. For example, staff must make a contribution for meals and pay for private telephone calls, see RSPM 2.1.

Monthly The department must provide residents, or their administrators a monthly statement statements of of money received and spent. Residential services are provided with monthly client funds statements which must be reconciled against all transactions for expenditure.

The financial plan A financial plan must be developed and approved for every resident whose money is managed through the Resident Trust Fund. The financial plan is to be developed by the:  resident  administrator  supervisor manager. The plan allocates the money available to residents and what it may be spent on. Staff must only expend funds according to the approved financial plan. The plan is to be kept in the finance section of the ASF. Financial plans must be reviewed annually.

Unplanned Occasionally there may be a need to use funds for a purpose not anticipated in the expenses financial plan, for example, a resident may need extra money for:  new clothing  an unanticipated outing membership fees of a local sporting or leisure club. The administrator must approve unplanned expenses, before any purchases can be made or fees paid.

Resident Residents should be involved and informed about their financial plan. Where inclusion possible, they should be encouraged to manage their own money independently especially for small or regular purchases. This requirement can be included in routines and their financial plan.

Resources  Client Expenditure Recording System (CERS) policy manual and tools – comprehensive instruction and forms for the management of people’s finances in Department of Human Services disability residential services. Available on the DAS Hub.  Disability Services - Department managed Residential Charges Policy – Long Term Accommodation and Facility Based Respite – contains the current accommodation fees payable in department managed accommodation services. Available on the Department of Human Services website at: http://www.dhs.vic.gov.au/disability  Managing utility costs – tip sheet to assist in managing and reducing use of electricity, gas and water. Available on the DAS Hub  Rights and Accountability: Management of Money Policy – a policy for disability service providers and their staff on their roles and responsibilities in relation to managing the money of people with a disability living in residential services managed or funded by the Department. Available on the Department of Human Services website at: http://www.dhs.vic.gov.au/disability

6.3 Handling funds in respite services

Issued: August 2012 FBR – Y STJ/GH/I/LTR/RTF – N Contents What monies can staff accept? Process for receiving spending money When a client holds their own money or valuables Housekeeping money Resources

What monies can Staff can only accept cash as personal spending money for respite service users. staff accept? Staff must not accept respite and accommodation charge payments. These are made by, or on behalf of the person, to division finance.

Process for When respite service staff receive money, the following processes apply: receiving  they must check the amount given and immediately provide a receipt to the spending money family, carer or service user, as appropriate  if the service user arrives independently, staff must: – receipt the amount given – have it countersigned by another staff – provide a receipt to the family, carer or service user the amount received must be documented in the Record of Client Expenditure form. Cash provided should be secured in a locked tin which must be stored in a locked safe or cabinet.

When a client If a respite service user retains their own money or valuables, the following must holds their own apply: money or  a Release form must be completed. This form releases staff from responsibility valuables should the money or valuables be lost or stolen  a Release form should be signed if a respite service user brings valuable personal property to the service, or when it is known they are retaining spending money. The Release form must be kept on file and only needs to be completed once.

Housekeeping Housekeeping money is made up of departmental funds which are provided to pay money for groceries and, in some divisions, utilities. This money is department funds and paid directly to group homes. When using housekeeping money, staff must:  clearly document cash spent  provide receipts complete a Declaration of Expenditure form when receipts cannot be obtained. All recording forms are pre-printed and available from management.

Resources  Rights and Accountability: Management of Money Policy – a policy for disability service providers and their staff on their roles and responsibilities in relation to managing the money of people with a disability living in residential services managed or funded by the Department. It is on the Department of Human Services website at: http://www.dhs.vic.gov.au/disability  Disability Services – Department managed Residential Charges Policy – Long Term Accommodation and Facility Based Respite. Contains the current accommodation fees payable in department managed accommodation services. Available on the Department of Human Services website at: http://www.dhs.vic.gov.au/disability

6.4 Critical client incidents and non-critical client events

Issued: October 2015 Instruction applies to: All services Contents Overview What is the Critical Client Incident Management Instruction? Managing and reporting critical client incidents Completing a critical client incident report Divisional responsibility for after-hours support When a manager must be notified immediately (day or night) When notification to a manager can wait until the next business day Additional reports and notifications may be required Recording and analysing non-critical client events Where to store the Non-critical client event log Types of non-critical client events to record Resources

Overview Reporting critical client incidents and non-critical client events that occur in Disability Accommodation Services form an important part of the ongoing process of monitoring practice and promoting quality improvement. The process ensures incidents and events are managed appropriately and all people involved are adequately supported. Serious incidents involving a resident are managed according to the department’s Critical Client Incident Management Instruction, and this must be followed by all directly managed services and funded agencies. Non-critical client events do not fall within the critical client incident management reporting requirements but still need to be recorded and captured at a local level to support and improve service delivery to residents. Non-critical client events are to be recorded in department-managed residential services and regularly used by local management to monitor practices and identify quality improvement strategies. This may reduce the risk of non-critical client events escalating to critical client incidents.

What is the Critical client incidents are those that have or may have a significant adverse impact Critical Client on clients, service providers, the community, the department or government. Incident Within the department’s Critical Client Incident Management Instruction, there are Management two categories of critical client incident: Instruction? Category one These are the most serious incidents. A category one incident is an incident that has resulted in a serious outcome, such as a client death in unusual or unexpected circumstances, or severe trauma. Category two These incidents involve events that threaten the health, safety and/or wellbeing of clients or staff. The department’s Critical Client Incident Management system ensures:  the appropriate response and support are provided to all involved  strategies are in place to reduce the recurrence of similar and serious incidents  appropriate Ministers, the Secretary, Executive Directors, Directors and divisional management are accurately and promptly informed  analysis of critical incidents assist and guide policy development.

Managing and Staff must follow the Critical Client Incident Management Instruction and: reporting  manage the incident appropriately critical client  ensure, as far as possible, that any person involved in the incident is adequately incidents supported, and supports including debriefing or counselling for residents or staff involved in an incident, and advocacy for residents affected are considered  make the required notifications  complete an incident report whenever a critical client incident occurs  if in doubt whether an issue is a critical client incident or a non-critical client event, report it as a critical client incident  ensure other staff are informed of the incident and any follow up actions or recommendations to be implemented by documenting this in the shift report and resident files, as required by divisional process  notify the family of incidents that involve injury or hospitalisation of a resident, according to any agreed prior arrangements  notify the manager immediately if unsure of the category of an incident, or if the circumstances related to the original report change  complete other reports required such as the Disease, Injury, Near Miss, Accident (DINMA) reports and WorkSafe Incident Notifications.

Completing a Staff must use the department’s Critical Client Incident Report template. The report critical client must be written clearly and include all factual information relating to the incident incident report including:  the exact circumstances of the incident including what happened, where and when  the name and role of every person involved in, or as a witness to the incident  the names and dosages of medications when incidents involve medication  actions taken by any person, for example, applied first aid, called fire brigade, ambulance or police  any instruction received from the manager or emergency services, stating what you were asked to do and by whom  actions you took including what you did, when and where. This is to ensure all required and appropriate actions have been undertaken, including the provision of supports to residents and staff involved, and to check the incident is categorised appropriately. Staff should be aware that incident reports may be used in formal processes such as investigations into injuries and deaths. The reports are public records, so it is important that they do not contain comments or personal judgements that cannot be verified. Incident reports must be submitted via the division critical client incident report lodgement process within the specified timelines.

Divisional Divisions are to ensure that appropriate management support is provided after responsibility hours. The reporting requirements for critical client incidents do not vary between for after-hours business and after hours so divisions must ensure that staff who will be providing support this support:  have sufficient knowledge and experience to provide the required support  are able to provide any immediate supports that may be required at the location of a critical client incident or provide a referral for this to occur  have a good knowledge of the department’s Critical Client Incident Management Instruction (including reporting process and timelines) and the Residential Services Practice Manual.

When a If any of the following incidents occur, a manager (the regular line manager during manager must business hours or the manager providing after hours on-call support), must be be notified contacted immediately regardless of the time and verbally notified (in addition to immediately the completion of the incident report) where any of the following occur(s): (day or night)  the death of, or serious injury to, a resident or staff member  allegations of, or actual, sexual or physical assault of a resident or staff member by a staff member  physical assault by a resident where the victim requires medical attention  a fire involving death or serious injury  a fire involving closure or significant damage to parts of a building or its contents  serious property damage that makes the building unsafe or unusable  injury or deterioration in health that requires urgent medical attention, hospital admission or attendance by an ambulance (that is not a requirement of an existing management plan such as an epilepsy seizure management plan)  medication errors where a pharmacist, doctor or Poisons Information Line advises the resident requires urgent attendance at or treatment by a medical practitioner (including a hospital emergency department)  an event occurs that has the potential to involve the relevant Minister, or subject the department to high levels of public or legal scrutiny. Where a manager must be contacted immediately, staff must make all attempts to speak directly to a manager rather than leaving messages, and must follow the manager’s direction. The manager receiving notification of the incident must determine if they should notify the DAS manager immediately or wait until the next business day, based on local protocols or the seriousness of the incident.

When If any of the following occur(s) the regular manager should be notified the next notification to business day. Immediate notification to a manager after hours does not need to a manager can occur: wait until the  threats made against residents, staff, visitors or members of the public next business  criminal behaviour resulting in police intervention, excluding assault that day requires immediate notification  sexualised behaviour of a concerning nature, excluding sexual assault that requires immediate notification  general unethical behaviour by staff that does not meet the requirements for immediate notification

Additional Some critical client incidents will require completion of additional relevant reports. reports and For example: notifications  The incident involved occupational violence: may be – Complete the Occupational Violence Risk Assessment Management Tool required (OVRAMT) post incident tool – Complete a Disease, Injury, Near Miss, Accident (DINMA) report. –  A staff member was injured or nearly injured: – Complete a DINMA report – The Health and Safety Representative (HSR) must be notified.

 Any person on the property including residents, staff, contractors or visitors, was seriously injured and required medical attention: – Complete a DINMA report – Notify WorkSafe immediately by phone and send a completed Incident Notification form to WorkSafe within 48 hours. See RSPM 3.15, Serious incident notification to WorkSafe Victoria.

 If the incident involves a department vehicle: – The driver must complete the Insurance claim form, and a DINMA report. – If the vehicle is a bus, the fleet manager must be informed as a Transport Safety Victoria, bus incident notification may need to be completed and lodged.

 If a resident dies: – The most senior staff member on duty in the house at the time of the death must contact the coroner to notify them of the death of a resident living in a department managed residential service. – The DAS Manager should notify the Community Visitors regional convenor of the death. See RSPM 6.8.

Recording and Non-critical client events are events involving a resident that do not require incident analysing non- reporting but still need to be recorded and used at a local level to identify trends critical and develop strategies to prevent future critical client incidents. client events These events are to be recorded using the Non-critical client event log (event log) before the end of the shift when the event occurred to ensure all events involving a resident can be readily accessed and analysed by staff and their line manager at the local level. Where multiple residents are involved in an event, a notation should be made in each resident’s event log to describe their role and how they were affected, to ensure all non-critical client event information for each resident can be considered together. Where details of an event are recorded in another location, a brief notation in the log is adequate with a cross reference to the location of the detailed event description. House supervisors must date and sign or initial any new events on the event log on their first shift after the event, to confirm that the event has been recorded correctly as far as they can determine and incident reported where appropriate. The house supervisor should also confirm the necessary follow up actions have been identified and have occurred to prevent future occurrences. The event log can also be used for discussion at group home staff meetings or individual Professional Development and Support discussions as appropriate. The event log must be reviewed by the house supervisor and operations manager on a monthly basis to identify issues or trends of concern and develop actions to prevent, reduce or minimise the impact of future occurrences. The initial analysis can be completed by a key worker, however a formal monthly analysis must occur between the house supervisor and operations manager. Any actions identified in this analysis are to be documented in the action plan at the end of the event log. If the event log contains any events, it is to be signed by the house supervisor and operations manager after each monthly analysis (regardless of whether any actions are identified), filed in the resident’s Accommodation Services File(ASF) and a new log commenced. Divisions or areas may require house supervisors to forward the event log to line management more frequently in some circumstances based on local arrangements. Non-critical events that do not involve specific residents such as minor neighbourhood concerns about vehicle parking or general noise levels, the loss of Client Expenditure Recording System (CERS) bank cards or accidental withdrawal from the wrong bank account do not get recorded as Non-critical client events and can be recorded in shift reports.

Where to store A Non-critical client event log that contains any events must be signed and filed the Non- in hard copy on the resident’s current ASF on a monthly basis, after the review critical client and analysis by the house supervisor and operations manager. The log must be event log made available to Community Visitors on request.

Types of The following are types of non-critical client events that are to be recorded on the non-critical Non-critical client event log: client events to record  Health and Wellbeing Concerns (Code HW)  Anticipated deterioration of a known medical condition in a resident, where any contact is made with NURSE-ON-CALL, a medical practitioner or allied health professional. (Unanticipated deterioration of a known condition or the onset of an illness, where the resident attends, or receives treatment from a medical practitioner, is reported as a category 1 or 2 critical client incident. If doubt exists whether deterioration was anticipated or not, this should be reported as a critical client incident).  Medication (Code MED)  Any refused or missed medication or incorrect administration that a pharmacist, doctor or Poisons Information Line has advised does not require attendance at or treatment by a medical practitioner. (Errors leading to attendance at or treatment by a medical practitioner are reported as a category 1 or 2 critical client incident).  Accidents/Falls (Code AF)  Any accident or fall involving a resident that either does not lead to an injury or the resulting injury does not require treatment by a medical practitioner. (Injuries requiring treatment by a medical practitioner, or unexplained or concerning injuries, are reported as a category 1 or 2 critical client incident).  Concerning Behaviour (Code CB)  Any PRN medication given for behaviour management that is authorised in a Behaviour Support Plan. (PRN medication for behaviour management that is not authorised is reported as a category 1 critical client incident). The focus of the recording in the event log is to capture the details of the behaviour and what occurred before and after, in order to identify patterns and ways to prevent events occurring or escalating to critical client incidents. All other PRN medication (not for behaviour management) can continue to be recorded in a resident’s file notes. Other (Code OTH)  Any other events that raise staff concerns about the wellbeing of residents that are not serious enough to be reported as a critical client incident. These should also be raised with the manager as soon as possible on the next business day, to confirm they should not be reported as a critical client incident.

Resources  Non-critical client event log – A recording form for events that do not require incident reporting, but still need to be recorded and used at a local level to identify trends and develop strategies to prevent future critical client incidents.  Responding to allegations of physical or sexual assault – A department instruction that sets out management and reporting requirements relating to allegations of assault. Available on the DHS Hub.  Client incident management and reporting – Reporting policy, report templates and guides. Available on the DHS Hub.  Transport Safety Victoria – Bus safety information and incident notification forms available at: http://www.transportsafety.vic.gov.au/bus-safety  When a person dies action checklist – A checklist to help ensure all requirements are met in the event of a person’s death. It is on the DAS Hub.  When a person dies incident reporting guide – A guide to assist in writing the incident report in the event of a person’s death. Available on the DAS Hub.  Critical Incident Response Management (CIRM) - Detailed information, policies, guidelines and contacts for CIRM. Available at http://intranet.dhs.vic.gov.au/resources-and-tools/procedures-and- processes/critical-incident-response-management-service  Employee Assistance Program - Detailed information, policies, guidelines and contacts for the Employee Assistance Program. Available at http://intranet.dhs.vic.gov.au/resources-and-tools/guides-and- manuals/employee-assistance-program

6.5 Damage caused by people living in residential services

Issued: August 2012 Applies to all Contents Procedures to follow if a person causes damage What is intentional damage? Who pays for damage? If the person must pay for the damage What if the person who caused the damage, or their administrator, is unwilling or unable to pay? If the police have decided the damage is a criminal matter Resources

Procedures to Staff must refer to the Critical Client Incident Reporting Policy to determine what follow if a person type of report should be completed when damage occurs. The manager must be causes damage informed immediately if damage:  is related to property belonging to a member of the public results in the police being involved. The report for the circumstances above must contain: – the name of the person responsible – the type and extent of the damage and the circumstances of the incident – if the damage was intentional or unintentional – the name and address of the person whose property was damaged – the names of any witnesses.

What is Intentional damage is damage which is deliberate. To be intentional a resident intentional must understand the outcome of their action. This includes damage to property damage? belonging to:  the department  co-residents  staff  a member of the public. Staff must follow the Critical Client Incident Reporting Policy in conjunction with this instruction.

Who pays The damage may be paid for by the resident or the department. Responsibility for for damage? costs will be determined by division management based on considerations including:  if the damage was intentional, or unintentional  if the resident was being supported appropriately when the damage occurred.

If the person The supervisor and manager should determine the cost of the damage according must pay for the to quotes or receipts. This information must be provided to the resident’s damage administrator. The administrator will decide how the payments will occur. For example, the administrator can arrange payment by:  making a direct payment to the person whose property was damaged  requesting payment be made out of the client funds available at the group home. The administrator may suggest replacing or repairing the damaged item.

What if the person If the resident or their administrator refuses to pay, after it has been determined who caused the they are responsible for the costs, the matter should be referred to the damage, or their department’s Legal Services Branch. If the resident does not have sufficient funds administrator, is they, or their administrator, should make arrangements to make the payment by unwilling or instalments, or when funds become available. This arrangement should be unable to pay? documented and a copy placed with the resident’s ASF financial information.

If the police have If the police decide the damage is a criminal matter, client services should be decided the involved to ensure the resident is represented and understands the proceedings. damage is a The court will determine if the resident is guilty and may provide directions criminal matter regarding how the resident must pay. The supervisor and manager are required to determine the cost of the damage and provide the police with this information.

Resources  Critical Client Incident reporting – reporting policy, report templates and guides. Available on the DHS Hub.  House maintenance guide – a guide for accessing maintenance and repairs in group homes. Available on the Department of Human Services website at: http://www.dhs.vic.gov.au/about-the-department/documents- and-resources/policies,-guidelines-and-legislation/disability-supported- accommodation-house-maintenance-guide  Singleton Equity Housing Limited and properties owned or managed by other housing options, follow the maintenance information provided at the site.

6.6 Missing people

Issued: August 2012 FBR/GH/I – Y STJ/LTR/RTF – LD Contents Overview Confirming if a resident is missing If a resident is confirmed missing Informing and reporting When the resident is found Resources

Overview Residential services are generally voluntary and residents have freedom of movement within their community unless they have an authorised restrictive intervention or legal order in place. This must to be balanced with reasonable actions to ensure resident’s who require support to access the community safely are not placed at unreasonable risk, see RSPM 1.2, 4.2. The level of support and the resident’s safety risks are to be documented in their profile and plans to ensure appropriate action can be taken if the resident’s whereabouts are unknown.

Confirming if Staff must take the following steps to confirm if a resident is missing: a person is missing If Then the resident is  the resident will have a response plan in their file (consult known to wander the plan for the steps to follow) a resident goes  check the diary to see if the resident is at a pre-arranged missing from the meeting or appointment residential service  ask others at the residential service if the resident mentioned they were going out and where they were going  search inside and outside the residential service and nearby properties  search the resident’s favourite places a resident goes  search the immediate area missing on an  notify staff at the residential service or the manager outing  seek assistance from the police, or bystanders, if the resident is at risk when on their own a resident does not  if the resident was at a particular organisation, contact the return to the organisation to find out information about the resident’s residential services whereabouts at the usual, or  if a pre-booked taxi was used, contact the taxi service to allocated time determine if, or when the resident, was picked-up or dropped off.

If a person is As soon as a resident is confirmed missing, staff must notify the manager confirmed immediately and: missing If the resident: Then

 has a Supervised  report the matter to the police immediately and: Treatment Order  provide information documented on the Missing  is at risk to themselves or Person Identification form the community when  provide a photograph of the resident unsupervised  record in the communication book the name, rank and personal identification number of the police officer consulted  does not have a  the police do not need to be contacted Supervised Treatment immediately (the police must be contacted if the Order resident is not found within an hour of being  is not known to wander confirmed missing)  is not a risk to themself or  in case the police need to be contacted, compile the community when a description of the missing resident by unsupervised completing the Missing Person Identification form and have a recent photograph of the resident, should it be required  has not been found within  telephone 000 to report the missing resident an hour of being  give the police a copy of the Missing Person confirmed missing Identification form and a recent photograph of the missing resident  record in the communication book the name, rank and personal identification number of the police officer who compiled the report  decide whether to contact the police earlier than an hour depending on the situation and the resident involved (management must assist with this decision, as required).

Informing and Step Action reporting Up-date the  management must be informed of the missing resident manager  if a report is made to the police, the staff member who made the report must inform their manager immediately inform the missing  the manager must inform the missing resident’s family and resident’s family develop a plan to keep them up-dated complete a Critical  the staff member on duty when the resident went missing Client Incident must complete an Critical Client Incident Report Report  the category of the incident will depend on the circumstances and the resident involved, see RSPM 6.4

When the Staff must immediately inform: person is found  their manager  other relevant staff  the family  the police, if the resident was not found by them.

Staff must ensure the resident’s wellbeing by:  checking for physical or emotional injuries  assessing and arranging medical attention, as required.

Resources  Critical Client Incident reporting – reporting policy, report templates and guides. Available on the DHS Hub: http://intranet.dhs.vic.gov.au/resources-and-tools/policies-and- standards/incident-reporting-departmental-instruction  Missing person checklist – a list of tasks to complete if a person is missing. Available on the DAS Hub.  Missing Person Identification form – a form to provide emergency services with relevant information. Available on the DAS Hub.

6.7 Responding to physical and sexual assault

Issued: August 2012 Applies to all Contents What is physical assault? What is sexual assault? Issues that are not reportable as physical or sexual assault Reporting allegations to the police If staff suspect a client has been sexually assaulted What to do when an allegation is made Supporting victims of sexual assault Who must report the allegation to the police? Staff actions Resources

What is physical For the purpose of this instruction, physical assault is defined as the application of assault? force which causes physical injury requiring medical attention. This definition is not as broad as the definition provided in the Crimes Act 1958, to exclude some actions which people with a disability may take due to a lack of social expectation awareness.

What is sexual Sexual assault includes rape, assault with intent to rape and indecent assault. assault? Examples of indecent assault include:  unwelcome kissing or touching of a person’s breasts, buttocks or genitals  forcing a person to watch pornography or masturbation.

Issues that are There are some behaviours that do not require a Critical Client Incident Report and not reportable reporting to police. These are treated as non-critical client events and they include: as physical or  minor shoving between residents sexual assault  inappropriate touching by a resident who lacks understanding of the behaviour  exposure in a public place by a resident in some contexts  a resident does not understand the significance of their behaviour, because of their cognitive ability, for example, a resident may be unable to distinguish between the significance of touching someone on the arm, as opposed to touching them on the breast. The manager is to be informed, see RSPM 6.4, and an appropriate support plan implemented and monitored. If staff are unsure as to the nature of the issue they should seek immediate advice from a manager.

Reporting Allegations of physical or sexual assault, are defined in the department’s allegations to Responding to Allegations of Physical or Sexual Assault policy, and must be the police reported to the police. Physical and sexual assault includes:  rape of or by a resident  rape or indecent assault by a staff member, volunteer carer or member of the volunteer carer’s household  the production of child pornography by a resident, staff member or volunteer  physical assault of a resident by a staff member, volunteer carer or member of the volunteer carer’s household (regardless of the need for medical attention)  physical assault of or by a resident resulting in medical attention being required (treatment by a medical practitioner)  physical assault of or by a resident involving a weapon, such as a knife, hammer or other object.

This instruction applies whenever there is an allegation a resident has assaulted, or been assaulted by:  another resident  a staff member  a volunteer carer  a visitor to the residential service  a family member  a community member.

If staff suspect a Some residents may be unable or unwilling to report a sexual assault. Staff client has been working with people with a disability must be aware of possible indicators of sexual sexually assault. These include: assaulted  significant behavioural changes which may include: – self-destructive behaviour – sleep disturbances – acting-out  persistent or inappropriate sexual play  physical symptoms caused by sexually transmitted diseases or pregnancy  complaints of physical symptoms, such as abdominal pain.

Staff who suspect sexual assault may have occurred must immediately discuss this with their manager, or after hours support. A medical review should also occur as soon as possible with immediate medical attention sought, if a resident displays physical or emotional signs of assault.

What to do Allegations of assault must always be treated seriously. When there is an when an allegation of assault, staff must: allegation is made  immediately takes steps to create a safe environment, if the threat remains  reassure and support the resident and advise them of what will happen next report the allegation to the police. If the victim or perpetrator has a cognitive disability, advise the police, an Independent Third Person (ITP), will be required. If the victim or perpetrator is less than 18 years of age, a parent, plenary guardian, or Independent Person (IP) must be present when they give a statement. The police are responsible for contacting the ITP or IP. Staff must not:  act as an ITP  interview the resident about the allegation, as this is a police role.

Some discussion may be required to:  ensure the resident’s safety  obtain a basic understanding of what has happened.

If the resident needs to talk about what occurred, listen and show concern. Depending on the resident’s age and status, notify their next-of-kin, or guardian, as appropriate. For further information, refer to the department’s policy: Responding to allegations of physical or sexual assault.

Supporting A resident’s feelings may be influenced by their initial reaction to the allegation. If victims of they sense a negative response, this may cause or reinforce feelings of guilt and sexual assault shame. If a sexual assault is disclosed, a helpful response may include:  letting the resident know you believe them  making it clear whatever happened is not their fault  reassuring them disclosing the assault is the right thing to do  telling them they are not is responsible for the assault. Sexual assaults reported to police are immediately referred to The Centre Against Sexual Assault (CASA). CASA provides 24-hour advocacy and counselling and will support the victim to decide what they want to do.

Who must report The allegation must be reported to the police by: the allegation to  the most senior staff member on duty at the residential service the police?  the person who was told of the alleged assault, if a senior staff member was not on duty at the time.

Staff actions If the alleged perpetrator is present and is continuing to threaten any person, then staff are to call ‘000’ to seek immediate assistance.

Resources  Critical Client Incident reporting – reporting policy, report templates and guides. Available on the DHS Hub: http://intranet.dhs.vic.gov.au/resources-and-tools/policies-and- standards/incident-reporting-departmental-instruction  Independent Third Person, Office of the Public Advocate – for comprehensive information on role and functions of the Office of the Public Advocate, see: http://www.publicadvocate.vic.gov.au and click on ‘Services’  Responding to allegations of physical or sexual assault – a department instruction that sets out management and reporting requirements relating to allegations of assault. Available on the DHS Hub.

6.8 When a person dies

Issued: August 2012 Applies to all Contents The role of the Coroner If staff believe a person has died at the residential service Who can determine if a person has died? When it is determined a person has died at the residential service If a person dies in hospital Role of the manager Removal of the body when a person dies at the residential service After the Coroner’s investigation Responsibility for funeral and burial arrangements The role of friends or staff in funeral arrangements Departmental inquiry into a person’s death Resources

The role of the The coroner may investigate deaths that must be reported to the Victorian Coroner Coroner by law. This includes deaths that:  are sudden  are traumatic or unexplained  occur in people who reside in residential or custodial services that are the responsibility of government (even if the death occurs elsewhere). This means it is mandatory to report the death of a resident of a department managed residential services, even if the person dies while absent from the service, for example, in hospital, on holiday or an overnight stay with family or friends. The Victorian Coroner is the only person who can authorise removal of their body from the residential service.

If staff believe a If staff believe a resident has died, they must: person has died  call an ambulance immediately at the residential  implement relevant first aid procedures, see RSPM 3.12, 5.16 service  follow directions provided over the telephone by ambulance personnel  note the time the resident was discovered  notify the manager as soon as possible.

Who can  The following people can determine if a resident has died in a residential determine if a service: person has died?  a doctor  ambulance personnel  other medical professionals.

When it is If it is determined that a resident has died at the residential service staff must: determined a  contact management person has died  contact police at the residential  document the names, rank and identification numbers of the police who attend service  discuss with management, the most appropriate person to contact the family, and ensure they are notified  provide verbal information requested by the police  not provide a written statement to the police at this time.

If a person dies If a resident dies in hospital, staff must: in hospital  inform the manager, or after hours support, as soon as possible.  check if the hospital has notified the family where the family is not present at the time the person dies. While the hospital has primary responsibility to notify next of kin and respond to any queries related to medical issues, a representative of the department is also required to make contact with the family. This may need discussion with the manager to determine the most appropriate staff member to make contact, for example, it would usually be the supervisor or manager but at times a key worker may have a close working relationship with the family and may make this contact. The contact must occur as soon as possible.  ensure the hospital is aware that the Coroner must be involved  inform staff coming on shift of the resident’s death.  follow the Critical Client Incident Reporting instruction, see RSPM 6.4.

Role of the The manager must ensure: manager  the family has been contacted by the most appropriate departmental staff person  the family is aware of the legal requirement for the Victorian Coroner to be notified of the death  the Coroner has been informed (regardless of where the death occurs)  where another service, such as police or hospital, state they have informed the Coroner, the manager must confirm this with the Coroners office  Critical Client Incident reports are completed and the Disability Accommodation Services manager is informed, see RSPM 6.4  the resident’s guardian has been informed of their death (orders cease upon death, but notification should occur as soon as possible).  support is arranged for co-residents and staff, this may include debriefing from the Critical Incident Stress Management service, or counselling through the Employee Assistance Program, see RSPM 2.4  requirements are completed according to the ‘When a person dies’ checklist  the Divisional Executive Director or delegate notifies the Community Visitors Program Manager of a resident death  the death is noted in the Client Records Information System (CRIS) and records are archived, see RSPM 6.1.5.

Removal of the When a resident dies at a residential service the Coroner, or their representative, body when a are the only people who can authorise removal of their body. In the metropolitan person dies at the area, the Coroner will arrange for the body to be taken to the Coronial Services residential service Centre. In rural areas, the resident’s body is usually taken by ambulance to the local hospital mortuary.

After the After the Coroner has investigated the death, the family, or person arranging the Coroner’s funeral, must arrange for the body to be collected by the funeral director. investigation

Responsibility for The family is usually responsible for funeral arrangements. If the resident does not funeral and burial have a family, advice should be sought from the State Trustees. The State arrangements Trustees take responsibility for burial when there is no one to arrange it. In this case there may not be a funeral service.

The role of friends The person arranging the funeral will decide who should be consulted, or asked to or staff in funeral participate in the funeral service. Sometimes a decision is made that a private arrangements service will occur where group home staff and other residents may be excluded from attending. Where this occurs, the group home may choose to hold its own memorial or participate in some other event or ritual to remember the resident, for example by planting a memorial tree in the garden. This can be an important part of the grief process. If residents or staff require support to manage the death of a resident, they should access the Australian Centre for Grief and Bereavement. Staff may also access the Employee Assistance Program (EAP), see RSPM 2.4.

Departmental The death of a resident is always treated as a Critical Incident, see RSPM 6.4. inquiry into a Many Critical Client Incidents are reviewed and in some cases the department may person’s death investigate a resident’s death.

Resources  Critical Client Incident reporting – reporting policy, report templates and guides. Available on the DHS Hub: http://intranet.dhs.vic.gov.au/resources-and-tools/policies-and- standards/incident-reporting-departmental-instruction –incident reporting policy, report templates and guides. Available on the DHS Hub  State Coroners Office of Victoria – telephone: 1300 309 519. Available at: http://www.coronerscourt.vic.gov.au  State Trustees – helps people with their financial needs, telephone: 03 9667 6444. The website is located at: http://www.statetrustees.com.au  When a person dies action checklist – a checklist to help ensure all requirements are met. Available on the DAS Hub.  When a person dies: incident reporting guide – a guide to assist in writing the incident report in the event of a person’s death. Available on the DAS Hub.  Australian Centre for Grief and Bereavement – provides information about counselling and support services. Available at: http://www.grief.org.au

6.9 Wills and deceased estates

Issued: August 2012 Applies to all Contents Who can make a will? What is testamentary capacity? Witnessing a will and making an affidavit Role of support staff What if a person dies without a will? What if the person who died had unpaid bills or debts? Resources

Who can make Anyone who has testamentary capacity can make a will. The Supreme Court can a will? also make a will on behalf of a person who lacks the capacity to do so.

What is Testamentary capacity means at the time of making the will the person: testamentary  understands the nature and effect of what they are doing capacity?  knows in general terms what property they own and can dispose of  can judge the claims different people may have on their estate.

Witnessing a For a will to be valid, it must be signed by two independent witnesses aged over will and making 18 years of age. A person’s partner should not be a witness. Witnesses should also an affidavit not be beneficiaries of the will. If there is any reason why a person’s capacity to make a will may be challenged at a later date, it is advisable to ask a GP or solicitor to witness the will and swear an affidavit as an attachment. In the affidavit, the GP or solicitor must confirm the person has testamentary capacity when making the will.

Role of It is not the role of staff to: support staff  ensure residents have a will. This is the responsibility of the resident or their guardian.  be involved or assist with preparing a resident’s will.

Additionally, staff must not:  assess a resident’s capacity to make a will  act as an executor for a resident’s will. In situations where staff are made executors without their knowledge, they must renounce the appointment by filing an affidavit with the Register of Probates and arrange for the court to appoint someone else.  benefit from the estate of a resident they support. In cases where staff are named beneficiaries without their knowledge, they should renounce this  knowingly attempt to benefit from the estate of a resident.

Staff can refer residents to an appropriate service such as a solicitor, the Community Legal Centre or State Trustees if they want to make a will, or their family requests a will to be made on their behalf.

What if a When a resident dies without a will: person dies  The manager must notify the client services officer at the State Trustees and without a will? arrange for a letter to be written advising them of: – the person’s death – details of any known assets and liabilities – next-of-kin, if known. The State Trustees are responsible for the estate until an administrator is appointed. The deceased resident’s former financial administrator is not the administrator of their estate. The next-of-kin, or interested parties, can apply to the Supreme Court to administrate the estate. If no one applies to be the administrator, State Trustees will be responsible for administering the estate. This includes:  paying any debts  distributing the estate to beneficiaries. State Trustees are responsible for arranging the collection of the resident’s property and holding it in storage until it can be distributed to beneficiaries. Prior to the property being collected, the manager should arrange for small items to be stored in a locked cupboard, or safe at the residential service. Money must be returned to the Resident Trust Fund. Larger items, such as a chair, table or audio- visual equipment, may remain in the residential service, or be stored in a secure locked garage or shed, if available.

What if the If the resident has unpaid bills or debts, the organisation or individual owed person who money (the creditor) must seek payment from the executor or administrator. died had unpaid bills or debts? If Then the resident has a there will be an executor managing their estate (refer the will creditor to this person) the resident does their assets will be frozen until an administrator is appointed not have a will (the administrator will be State Trustees or a person appointed by the court – refer the creditor to this person).

Resources  National Association of Community Legal Centres – has links to local Community Legal Centres which provide free, confidential advice and assistance about a variety of legal matters. Available at: http://www.naclc.org.au  State Trustees – helps people with their financial needs. Available at: http://www.statetrustees.com.au

In this section

7 Positive behaviour support 7.1 Reducing and preventing behaviours of concern 7.2 The Senior Practitioner 7.3 Restrictive interventions 7.4 Behaviour Support Plans 7.5 Compulsory treatment

RSPM application to service type Each instruction has service type and instruction application codes to assist to identify how the specific instruction applies to supported accommodation by service type. Service type:

FBR facility based respite GH group homes

STJ short term justice LTR long term rehabilitation program

I Sandhurst and Colanda RTF residential treatment facility (DFATS)

Instruction application:

Y instruction applies in full

N instruction does not apply to service type

Partial application. Service required to implement principle of instruction but service not generally P directly responsible for planning, monitoring and reviewing components of instruction

Locally determined based on client plans, service model and protocols. Applicable to STJ, LTR and LD RTF only

7.1 Reducing and preventing behaviours of concern

Issued: August 2012 Applies to all Contents Overview Factors that impact on behaviour Role of staff When is an authorised BSP required? Resources

Overview Behaviours that impact on an individual and those around them is more than behaviours defined as behaviours of concern and use of restrictive interventions. Support strategies that provide opportunities for a resident to develop skills for meaningful interaction and participation, in conjunction with appropriate health management will prevent or significantly reduce the risk of behaviours of concern or withdrawal. All life areas need to be considered and addressed as far as possible before any restrictive interventions can be considered, authorised or implemented. Also see RSPM Preface: Promoting positive practice and RSPM 4.3.

Factors that All human beings behave according to a variety of factors that include but are not impact on limited to: behaviour  personal life experiences  attitudes and expectations of the individual and others  physical and social environments  physical, mental and oral health People with a disability may also be impacted by:  the cognitive and physical impacts of disability  medications they take  discrimination, for example, being denied access to education or employment  poor access to information, support or physical environments  exclusion from activities, conversations and decisions.

Role of staff Staff are to follow the Person Centred Active Support (PCAS) method of working with resident’s and seek specialist advice and assistance as directed by the resident needs, support plan and related parts of the RSPM. Residents are to be supported to develop and maximise:  good health  communication skills  relationships and social connections  choice and decision making  skills to manage and cope with change The resident’s support plan, implemented in conjunction with the resident along with RSPM sections 4 and 5, provide guidance about the information and support activities required for each individual resident.

When is an A Behaviour Support Plan (BSP) may be a useful support tool where a resident has authorised behaviours of concern that are managed without the use of restrictive interventions. In BSP required? this circumstance, the use of the BSP does not require authorisation or reporting to the Office of the Senior Practitioner as no restrictive interventions are used. An authorised Behaviour Support Plan is required when a resident has significant behaviours of concern where supports or interventions require the use of restrictive practices, see RSPM 7.3, RSPM 7.4. Staff must not implement any intervention that is restrictive without a BSP that is developed using the Positive Behaviour Support framework, approved by the Authorised Program Officer (APO), explained to the resident by an Independent Person (IP) and lodged with the Office of the Senior Practitioner (OSP).

Resources  Positive Behaviour Support framework- a practice framework designed to reduce use of restrictive interventions and improve quality of life for people with behaviours of concern. Available on the Department of Human Services website at: http://www.dhs.vic.gov.au/about-the-department/documents-and- resources/reports-publications/positive-behaviour-support-getting-it-right-from- the-start

7.2 The Senior Practitioner

Issued: August 2012 Applies to all Contents Role of the Senior Practitioner Functions of the Senior Practitioner What is an Authorised Program Officer? Role of the Authorised Program Officer What is an independent person? Role of the independent person Resources

Role of the Senior The Disability Act 2006 states the role of the Senior Practitioner is to ensure: Practitioner  the rights of people subject to restrictive interventions and compulsory treatment are protected  appropriate standards for restrictive interventions and compulsory treatment are complied with.

Functions of The Senior Practitioner develops guidelines and standards with respect to the Senior restrictive interventions and compulsory treatment and provides: Practitioner  education and information with respect to restrictive interventions and compulsory treatment  information with respect to the rights of persons with a disability who may be subject to restrictive interventions or compulsory treatment  advice to improve practice in relation to restrictive interventions and compulsory treatment directions in relation to restrictive interventions, compulsory treatment and behaviour support and treatment plans The Senior practitioner is also to:  develop links and access to professionals, professional bodies and academic institutions for the purpose of facilitating knowledge and training with regards to clinical practice for staff working with persons with a disability  undertake research into restrictive interventions and compulsory treatment and provide information on practice options to disability service providers  evaluate and monitor the use of restrictive interventions across disability services  recommend improvements in practice to the Minister and the Secretary  perform any other functions specified or required by the Disability Act 2006.

What is an An Authorised Program Officer (APO) is any person approved and appointed by the Authorised Secretary of the Department of Human Services, to authorise Behaviour Support Program Officer Plans that require the use of restrictive interventions. Authorisation can be revoked by the Secretary.

The role of the The APO must ensure that strict criteria have been met in the development of the Authorised Behaviour Support Plan, including inclusion of least restrictive alternatives Program Officer consistent with the Positive Behaviour Support framework. Restrictive interventions can only be used when a resident displays behaviours which place them or others at risk, and behavioural change has not occurred with the introduction of non- restrictive interventions. The APO may only authorise the use of restrictive interventions where:  It is necessary to prevent the resident from: – causing physical harm to themselves or others – destroying property when doing so involves the risk of harm to themselves or others. Note; property destruction alone is not sufficient to implement a restrictive intervention.  evidence is provided that it is the least restrictive alternative for the resident and co-residents and the evidence describes: – the strategies that have already been tried – why the restriction is necessary – how the restrictive intervention will be reduced and removed overtime – how the option places the least restriction on co-residents.

What is an An Independent Person (IP) assists residents to understand the restrictive independent interventions in their Behaviour Support Plan. An IP must not: person?  be a disability service provider, or a representative or an employee of a disability service provider have any interest in a disability service provider which is providing, or has provided, disability services to the person with a disability. An IP toolkit, which contains a range of information for service providers and staff and persons who may act as an IP, is available from the Office of the Senior Practitioner.

Role of the The IP must explain to the resident: independent  the inclusion of restraint or seclusion in their BSP person  they can seek a review of the decision to include restraint or seclusion in their BSP  how the revised BSP will be different, should they already have a BSP.

The IP may report the matter to the Public Advocate if they consider:  the resident is not able to understand the proposed use of restraint, or seclusion, as detailed in their BSP  the requirements of the Disability Act 2006 are not being complied with.

Resources  Office of the Senior Practitioner – oversees, and provides information and resources on, the use of restrictive intervention and compulsory treatment. Available on the Department of Human Services website: http://www.dhs.vic.gov.au/for-individuals/your-rights/offices-protecting- rights/office-of-the-senior-practitioner

7.3 Restrictive interventions

Issued: August 2012 Applies to all Contents What are restrictive interventions? Least restrictive strategies must be tried What interventions are not reportable? Use of unauthorised restrictions may constitute abuse Locking doors and windows for security and safety The use of side rails on beds Chemical restraint Physical restraint Seclusion Approval of restrictive interventions Emergency use of restraint and seclusion Reporting requirements Role of support staff The role of the supervisor and manager Resources

What are A restrictive intervention means any intervention used to restrict the right or restrictive freedom of movement of a person with a disability. This includes: interventions?  chemical restraint – a chemical substance used for the primary purpose of behavioural control  mechanical restraint – the use of devices to prevent, restrict or subdue movement for the purpose of behaviour control  seclusion – the sole confinement of a person where the windows and doors cannot be opened by the person from the inside, or are locked from the outside. Staff should refer to the Disability Act 2006, Part 1 – Preliminary, Section: 3 for more detailed definitions of the above restrictions. Any action which impacts on a resident’s rights according to the Victorian Charter of Human Rights and Responsibilities Act 2006 must be viewed as restrictive, see RSPM Preface.

Least restrictive Least restrictive strategies must always be tried by following the Positive Behaviour strategies must Support framework. Staff must only apply restrictive strategies that are part of the be tried authorised Behaviour Support Plan (BSP). Restrictive interventions must be: 1. Part of a resident’s approved BSP 2. Administered in accordance with the resident’s approved BSP 3. Only applied for the period of time which has been approved by the APO 4. Have been explained to the resident by an Independent Person. To decide if an intervention is restrictive the intent or primary purpose needs to be determined. To do this staff must ask if the purpose intervention is to assist a resident with behaviour control or to restrict freedom of movement. Authorised restrictions on access to any area or common facility for one resident must be noted on the Residential Statements of all residents. The information must include strategies to reduce the impact on residents not subject to the restriction. If the intent or primary purpose is unclear, the intervention should be treated as restrictive, be authorised before it can be used and must be reported. Unauthorised restriction may breach duty of care, see RSPM 1.2.

What There are some restraint exemptions which are not reportable under the Disability interventions are Act 2006. These include: not reportable?  the use of seatbelts and seatbelt buckles to stop a resident removing the belt when in a moving vehicle  support straps to ensure a resident does not fall from a wheelchair  splints applied for therapeutic purposes  psychotropic medications prescribed to treat a resident’s psychiatric illness which has been diagnosed and documented by a psychiatrist. Prescribed treatment or therapy which is not reportable as a restrictive intervention must be documented as a specific management strategy in the resident’s health plan, and be reviewed by the relevant medical or health professional, see RSPM 5.2.

Use of The use of restriction without authorisation or application of a restriction outside unauthorised the specific circumstances described in the authorised Behaviour Support Plan may restrictions may be considered abuse. Examples of common restrictions include, but are not limited constitute abuse to:  straps or belts on chairs and bed rails used to stop or restrict a resident’s freedom of movement.  Restricting a resident’s access in or out of the residential service by locking doors and windows or blocking access to internal common areas or facilities including:  locks on kitchen cupboards and refrigerators to restrict access to food  turning-off the water supply to taps in bathrooms or kitchen, or restricting access to water  locking away personal items or clothing.

The following restrictive practices are abuse, see RSPM 1.2, and must never be used:  verbal threats and intimidation  exclusion from interaction and activities as a punishment  any action or directive which creates compliance through the use of fear. For example, ordering a resident to go to their room, or lie on the ground.

Locking doors Normal home security and safety measures are not considered a restrictive and windows for intervention. This includes: security and  a door being locked from the outside when a resident is absent (to protect safety their property from theft)  external doors and windows (which do not require a key to be opened from the inside) being locked for the purpose of deterring intruders  the front door being locked from the inside to ensure the safety of residents who require constant supervision when outside of the residential service. For example, residents with little or no understanding of road safety who may walk onto the road. For these residents the following must occur: – the safety issue must be noted in their support plan – the practice must be included in the Residential Statements of co-residents – written approval for door locking practices to be implemented must be provided by the Disability Accommodation Services manager – doors must only be locked when the resident for whom approval is applicable, is at the residential service – the locking mechanism should be able to be opened without a key. Where locking by key is the only viable option, the door must have a strike lock installed as required under the Capital Development Guidelines. – the approval must be reviewed every 12 months to ensure it: o remains necessary o is the least restrictive option for co-residents.

The use of side The use of bed side rails should only be considered in exceptional circumstances. rails on beds For example, consideration should be given to less restrictive interventions such as lowering the bed to its lowest level and placing a fall-out mat beside it, if there is a risk the resident may roll-out. Bed side rails represent the most restrictive option and can only be used where a comprehensive assessment by a qualified occupational therapist demonstrates they:  present a lower risk to the resident than not using them  are not for mechanical restraint purposes. The same therapist must specify the details of how and when bed side rails can be used. In this circumstance the APO needs to sight evidence, for example, an assessment tool, report or recommendation, which states the bedding system has been prescribed for therapeutic purposes, and not mechanical restraint. Any bed side rail system which has not been recommended following assessment by an occupational therapist, and prescribed by them, must be:  considered mechanical restraint  approved and reported as a restrictive intervention.

Chemical Chemical restraint medication must be authorised and administered in accordance restraint with the medication section of the RSPM. Staff should read the medication information provided by the resident’s doctor and pharmacist and contained in their BSP to understand the reasons why it is being prescribed. If the prescribing doctor details specific medication monitoring is required, it must be included in the resident’s BSP. If additional monitoring, other than observing the resident is required, the supervisor and manager must determine the capacity of staff to do this based on the:  requirements involved  skills of staff. Information from the pharmacist and prescribing doctor should be discussed at the staff meeting to ensure staff have a shared understanding of why the resident has been prescribed chemical restraint medication. If other medication changes occur, staff should ask the doctor if these may impact on the prescribed chemical restraint medication. If the doctor or pharmacist indicates the effect of chemical restraint medication may be altered, (even if the chemical restraint medication dose has not been altered), the information must be reported to the APO and the Office of the Senior Practitioner to determine if a variation to the resident’s BSP is required. Chemical restraint must be reviewed by the treating doctor at no more than four month intervals. A review must also occur annually (or more often if determined during the planning process) by the relevant medical specialist, for example, the psychiatrist, paediatrician, neurologist or gynaecologist.

Physical restraint Physical restraint is where a person is physically held by another person to prevent movement. Physical restraint may only be used in strict accordance with the OSP Direction on Physical Restraint as it presents a high risk of injury to all involved. Some forms of physical restraint in conjunction with specific risk issues that some individuals may have, can cause death so are prohibited. Applying unauthorised or prohibited physical restraint may be assault. Staff should never apply physical restraint unless it is part of an authorised BSP they have been trained to implement. Safety measures, such as holding a person’s arm for a brief period to stop them walking onto a road, is not considered physical restraint.

Seclusion Seclusion is the confinement of a resident to a room or part of a building that is locked or has a barrier used that stops their freedom to exit. Where seclusion is part of an authorised BSP staff must ensure:  the environment is suitable, including appropriate heating and cooling  clothing, food and medications are available  access is available to appropriate toilet facilities The maximum time period allowed for the seclusion must be documented in the BSP and adhered to.

Approval of Restrictive interventions cannot be applied without APO approval. The Office of the restrictive Senior Practitioner must be provided with a copy of the approved BSP within two interventions working days. Staff must not apply any intervention which may cause restriction without approval from the APO. The BSP guidelines available from the Office of the Senior Practitioner should be used to assist BSP development.

Emergency use Section: 147 of the Disability Act 2006, directs the circumstances whereby restraint of restraint and and seclusion may be used in an emergency situation on a resident who does not seclusion have an approved BSP that provides for the use of restraint and seclusion. For example, doors may be locked in a one-off emergency where a resident is engaging in behaviour which is placing co-residents and staff at risk. Locking the doors ensures the safety of the parties involved. Emergency restraint and seclusion can only be used if the approved disability service provider believes:  there is imminent risk of the resident causing serious physical harm to themselves or others and the conditions for use of emergency restraint or seclusion have been satisfied  it is necessary to use restraint or seclusion to prevent such risk.

In these cases, the following conditions apply:  the use and form of restraint or seclusion must be the least restrictive possible, given the circumstances  the use of restraint or seclusion must be authorised by the person in charge  the APO must be notified without delay of the use of restraint or seclusion  the manager must be notified of the intervention, including after hours.

Reporting The Restrictive Interventions Data System (RIDS) is the tool which must be used requirements to report restrictive interventions. RIDS must be completed monthly and forwarded to the APO. If interventions are not used, a nil-return must be lodged. The APO is required to report to the Office of the Senior Practitioner the use and form of restrictive interventions for the service outlets in which they are responsible. The APO is also responsible for ensuring returns are completed, as required, and forwarded to the Office of the Senior Practitioner within seven days of the end of each month.

Role of Staff should ensure they: support staff  participate in the development of support plans and BSP’s  implement tasks and activities outlined in resident support plans including PCAS  follow the directions of the approved BSP  do not apply unauthorised restrictions, see RSPM Preface, 1.2, 4.2  not apply authorised restrictions outside the specific authorised circumstances  attend training to ensure the health and safety of: – the resident to which the restriction is to be applied – colleagues – themselves  document the use of interventions, as required  are familiar with RSPM Section: 1.2: Duty of care in residential services  report concerns to their supervisor or manager.

The role of the Supervisors and managers must ensure assessments and documentation are supervisor and completed. This requirement will assist the APO to determine if the proposed manager restraint or seclusion is the least restrictive option. If a resident is subject to restrictive interventions, supervisors and managers must ensure:  the approval is current  the restriction is implemented as per the approved BSP  the restriction is recorded appropriately, as applied  the restriction is reported as directed by the Office of the Senior Practitioner  concerns regarding the use of the intervention are documented  staff, including casuals, who are required to implement the restraint or seclusion described by the BSP, are trained in inclusive communication strategies and have refresher training, as recommended  staff training needs are referred to division Learning and Development Co- ordinators. Where locked doors are in place, and it is not considered a restrictive intervention as outlined in this instruction:  the Disability Accommodation Services manager must confirm it is the least restrictive option for the resident involved and co-residents  strategies must be in place to reduce the impact on co-residents  written approval must be provided and reviewed every 12 months by the Disability Accommodation Services manager for the locked door practice to continue Where the use of bed side rails is in place and is not considered a restrictive intervention as outlined in this instruction, the APO needs to sight evidence to be satisfied the bedding system has been prescribed for a therapeutic purpose and not as mechanical restraint. This evidence may include:  an assessment tool  report and recommendations.

Clear written guidance is to be available to staff to guide local practice for use interventions that do not form part of a BSP. Managers and supervisors are to monitor staff practice to ensure, as far as possible, that unauthorised restrictive or abusive practice is not occurring.

Resources  Office of the Public Advocate (OPA) – protects and promotes the rights of people with a disability, see: http://www.publicadvocate.vic.gov.au  Office of the Senior Practitioner – oversees, and provides information and resources on, the use of restrictive intervention and compulsory treatment. Available on the Department of Human Services website: http://www.dhs.vic.gov.au/for-individuals/your-rights/offices-protecting- rights/office-of-the-senior-practitioner  Senior Practitioners direction on physical restraint – The direction from the Senior Practitioner on the prohibition of physical restraint. Available on the Department of Human Services website: http://www.dhs.vic.gov.au/about- the-department/documents-and-resources/reports-publications/physical- restraint-direction-paper-senior-practitioner  Restrictive Interventions Data System (RIDS) – the system for reporting the use of restrictive interventions. Available on the DAS Hub

7.4 Behaviour Support Plans

Issued: August 2012 Applies to all Contents What is a Behaviour Support Plan? What are behaviours of concern? Developing an authorised BSP Before lodging a BSP with the APO for approval To ensure a BSP can be implemented Review of an authorised BSP Role of the supervisor and manager Role of support staff Resources

What is a A Behaviour Support Plan (BSP) is a plan which is developed within the Positive Behaviour Behaviour Support framework and: Support Plan?  specifies a range of strategies when supporting a resident to alter their  behaviour  reduces the risk of harm. The plan includes proactive strategies to build on a resident’s strengths and increase their life skills. A BSP which has provisions for the use of restrictive interventions must be developed and authorised for implementation in accordance with the directions of the Authorised Program Officer (APO) and Office of the Senior Practitioner (OSP) and be explained to the resident by an Independent Person (IP). Authorised BSP’s are only used where a resident has a behaviour of concern that has not responded to positive behaviour support strategies. The BSP template provided by the OSP is to be used when restrictive interventions are proposed, as this format has been developed to assist with positive behaviour support and compliance requirements.

What are Behaviours of concern are behaviours which individuals who have a physical, behaviours of sensory or cognitive disability present with, or are at risk of presenting with, which: concern?  are severe dangerous behaviours  are not age or culturally appropriate  cause serious harm to the individual, others or property  without long-term support and intervention will continue to challenge usual support services and potentially form a barrier to the resident’s participation and inclusion in society.

Developing an An authorised BSP cannot be developed or implemented if the residents’ health and authorised BSP other life areas have not been addressed as far as possible, see RSPM 7.1. This includes any changes that may have occurred in the residents’ life or routines being investigated and appropriate support strategies provided. In addition, a functional behavioural assessment must be completed if:  a resident presents with behaviours which impact on their health and safety, or the health and safety of others  the known behaviour increases, or alters significantly. The Occupational Violence Risk Assessment Management Tool (OVRMAT) must also be completed, or reviewed, as required. Staff and managers should consult the Office of the Senior Practitioner resources to familiarise themselves with current behaviour support publications and information. Requests for specialist services support must be registered with Client Services Intake, or as per division processes.

Before lodging a BSP The BSP form must be completed in full to ensure the OSP is: with the APO for  able to register the BSP approval  follow-up queries or concerns. This includes the:  resident’s name, address, date of birth, gender and CRIS number  address and name of the service provider, for example, the DHS division and division address  details of other disability services which the resident accesses  completed and review dates  name, date and signature of the APO  name of the Independent Person and their relationship to the resident. If the resident has an appointed guardian, this person must be involved and be identified in the BSP as their guardian. Additionally, the BSP must clearly:  identify the type of restraint required  state the circumstances for which the approved restraint can be used  list the least restrictive options to be used first  explain the benefits of the intervention. Failure to check and complete these details may result in the BSP not complying with the requirements of the Act.

To ensure a BSP can When implementing a BSP it is important: be implemented  the environment is suitable for the requirements of the plan  co-residents receive information and support to ensure their wellbeing and safety, if incidents occur  managers refer training needs to division Learning and Development Co- ordinators to ensure staff have access to learning and development opportunities which: – develop communication skills with a focus on augmentative and alternative communication strategies (if these are recommended in the communication assessment)  is part of a positive behaviour support strategy which includes strategies to address: – communication issues – the safety of staff and others. If the BSP identifies staff require assault response training, this can only occur after positive behaviour support training has been delivered. This requirement must be clearly documented in the resident’s BSP.

Review of an Authorised BSP’s must be reviewed within a 12 month period, or at intervals as authorised BSP specified by the APO or OSP. BSP reviews should include those who were involved in the original planning process. A resident may request a BSP review at anytime. Staff should review the BSP at on-going staff meetings to ensure it is:  well understood  being implemented, as required.

Role of the The supervisor and manager must ensure: supervisor and  authorised BSP’s are in place, as required manager  staff understand their role in implementing BSP’s  staff training needs are included in the support information required to implement the BSP  staff have access to identified training and refresher training, as required  staff training needs are referred to division Learning and Development Co- ordinators  BSP’s are discussed at staff meetings to ensure they are understood and consistently applied.

Role of all staff Generally, staff have the primary responsibility for implementing BSP’s on a day-to- day basis. It is important staff:  participate, as far as possible, in the development of BSP’s  raise concerns or queries with the relevant person  attend training specific to BSP’s  complete necessary documentation as required by BSP’s  assist with the reporting requirements of authorised BSP’s  are familiar with RSPM Preface, 1.2, 4.2.  do not implement any restriction which is not part of the authorised BSP  follow the PCAS method of working with residents, see RSPM 4.4.

Resources  Behaviour Support Plan format and Practice guide. Available on the Department of Human Services website: http://www.dhs.vic.gov.au/about- the-department/documents-and-resources/forms-and-templates/behaviour- support-plan-template  Occupational violence – policy, implementation guidelines, procedures and tools. Available on the DAS Hub.  Occupational violence risk assessment and management – an electronic tool on preventing occupational violence. Available on the DAS Hub.  Office of the Senior Practitioner – oversees, and provides information and resources on, the use of restrictive intervention and compulsory treatment. Available on the Department of Human Services website: http://www.dhs.vic.gov.au/for-individuals/your-rights/offices-protecting- rights/office-of-the-senior-practitioner  Office of the Public Advocate (OPA) – protects and promotes the rights of people with a disability. Available at: http://www.publicadvocate.vic.gov.au  Strengthening rights in residential services: Policy statement – an explanation of the policy expectations of residential service providers in relation to residential rights. Available on the Department of Human Services website at: http://www.dhs.vic.gov.au/__data/assets/pdf_file/0010/599122/dis_act_20 06_residentialrightspolicy_pdf_-0610.pdf

7.5 Compulsory treatment

Issued: August 2012 Applies to all Contents What is compulsory treatment? Changes to treatment plans Resources

What is Compulsory treatment, residential treatment orders and security orders can only be compulsory applied if specific requirements are met. People who are authorised under the treatment? Disability Act 2006 to participate in making this determination include:  the Secretary of the Department of Human Services  the Senior Practitioner  Authorised Program Officers  the Adult Parole Board  the Secretary of the Department of Justice. Any resident who is subject to a compulsory treatment order must have an approved treatment plan. The treatment plan requirements outline the way that staff must support the resident.

Changes to A change cannot be made to a treatment plan unless it is approved by the Senior treatment plans Practitioner. The Senior Practitioner cannot approve a change to a treatment plan which relates to an increase in supervision or restriction, except in an emergency. The Victorian Civil and Administrative Tribunal (VCAT) is the only authority which can approve a variation in a treatment plan which involves an increase in supervision or restriction. If the Senior Practitioner approves a change in an emergency situation, they must immediately apply to VCAT for a variation of the treatment plan.

Resources  Office of the Senior Practitioner – oversees, and provides information and resources on, the use of restrictive intervention and compulsory treatment. Available on the Department of Human Services website: http://www.dhs.vic.gov.au/for-individuals/your-rights/offices-protecting- rights/office-of-the-senior-practitioner  Victorian Civil and Administrative Tribunal (VCAT) – VCAT deals with a range of disputes, appoints guardians and administrators and has the power to review certain matters under the Disability Act 2006. Available at http://www.vcat.vic.gov.au

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